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The Impact of Depression on ED Stays in ACS Patients

The Impact of Depression on ED Stays in ACS Patients

Studies suggest that about 30% of patients with acute coronary syndrome (ACS) experience symptoms of depression during hospitalization. These patients are nearly twice as likely to die from ACS or have recurrent cardiac disease when compared with those who aren’t depressed. The ED is often the first point of contact for treating ACS patients, and recent research suggests that psychosocial factors may impact aspects of care in the ED, including length of stay (LOS). Depression, ACS, & LOS It has been hypothesized that longer ED LOS may be associated with adverse clinical outcomes for those with ACS, especially among those with depression. In a recent issue of BMC Emergency Medicine, my colleagues and I sought to determine if depressed ACS patients experienced different ED care than those without depression. After reviewing data from 120 participants, we found that currently depressed ACS patients spent an average of 5.4 more hours in the ED than those who had never been depressed. Not surprisingly, our study also revealed that presentation to the ED during off-peak hours was associated with longer ED LOS. Interestingly, no significant associations were observed with other demographic variables that might be expected to influence ED LOS, including race, ethnicity, or neighborhood income. Furthermore, these variables did not appear to account for the association between depression and ED LOS. Making Interpretations Data from our study are preliminary, but indicate that there is likely an association between depression and longer ED LOS. There are several possible explanations for this finding. Depression may influence how ACS patients present to the ED, report their symptoms, recruit family members or friends to accompany...

Examining Length of Stay in 8-Hour Shifts

In previous research, studies have documented significant links between length of stay (LOS) over 24-hour periods and hospital occupancy, the number of ED admissions, and other factors. In the May 2012 Western Journal of Emergency Medicine, my colleagues and I published a study that looked at LOS in more discreet time periods than what earlier analyses have reported. We did this because ED crowding and volume can vary greatly during a given 24-hour period. We wanted to find out which factors were associated with LOS and whether this relationship was present during all or only specific 8-hour shifts. In our analysis, independent variables were measured during three 8-hour shifts. Shift 1 was from 7:00 am to 3:00 pm, shift 2 was from 3:00 pm to 11:00 pm, and shift 3 was from 11:00 pm to 7:00 am. For each shift, the numbers of ED nurses on duty, discharges, discharges on the previous shift, resuscitation cases, admissions and ICU admissions, and LOS on the previous shift, were measured. For each 24- hour period, the numbers of elective surgical admissions and hospital occupancy were measured, since these could not be measured in 8-hour time intervals. ED Length of Stay: Roles of Occupancy & Admissions On all three shifts, LOS increased by about 1 minute for each additional 1% increase in hospital occupancy. The mean hospital occupancy in our study was 94.9%; considering this high level of demand for inpatient beds, even a 1% increase in occupancy can lead to significant delays. The demand for inpatient beds often exceeds 100% capacity during the late morning and early afternoon hours on weekdays. To...

Addressing ED Crowding With Patient Flow Strategies

The number of ED visits has grown by 25% in the past decade, but the number of hospital EDs and inpatient beds has declined during that same time-frame, resulting in crowded conditions nationwide. Nearly half of EDs are operating at or above capacity, and few consistently achieve recommended wait times for all ED patients. The impact of ED crowding has been profound, leading to poor quality care, increased mortality rates, and lower patient and staff satisfaction. Major Findings on Improving Patient Flow In an effort to strengthen the evidence base for patient flow improvement strategies, Megan C. McHugh, PhD, and colleagues evaluated the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing ED crowding. Results were published in the September 13, 2011 Journal for Healthcare Quality. Participating hospitals implemented seven improvement strategies over 18 months as part of the collaborative. By the end of the study, four of the five hospitals had at least one fully implemented improvement strategy and had experienced modest improvements in patient flow, including reduced length of stay and fewer patients left without being seen. The improvement strategies and their impact varied considerably in the study, according to Dr. McHugh. “Several factors appeared to influence the impact of strategies, including ability to overcome implementation challenges, the timing of implementation, and the type of strategy selected. We also found that the staff time and expenses involved in the adoption of the ED strategies were highly variable.” Few studies have considered time and expenses associated with implementing patient flow strategies. In Dr. McHugh’s study, time spent planning and implementing the...

Expeditors in EDs: Facilitating Patient Throughput

Patients commonly experience lulls in their treatment during the course of their visits to the emergency department (ED). Following the triage of patients, they often wait to be brought back to a room. After initial assessments, they may also need to wait during the diagnostic testing and treatment phases. Wait times can also increase as physicians review patient information and make discharge or admission decisions. During these lulls, emergency physicians may be distracted by the urgent needs of other patients and delays can occur. Expeditors: The Maître d’ of the ED A smoother, more efficient operations model in the ED may help anticipate delays in care. For example, a maître d’ controls the flow of patrons in restaurants, ensuring that guests who arrive are seated quickly, their needs are met, and the table is turned over efficiently for the next customers. With this model in mind, we created a new position at Oregon Health & Science University (OHSU) called an “expeditor” who acted like a maître d’ at a restaurant. The expeditor’s primary responsibility was to ensure patient care moved forward. Other responsibilities included: Communicating with and reassessing patients in the waiting room. Rooming patients as directed by the charge nurse. Assisting with ambulance arrivals. Ensuring pain was controlled and providing analgesics as directed. Placing IVs, drawing labs, and running point-of- care tests. Assisting with the discharge processes (eg, removing IVs and helping patients get dressed). Facilitating patient transport to inpatient units. In the May 2011 Western Journal of Emergency Medicine, my colleagues and I had a study published in which we analyzed the effect of using an expeditor...
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